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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701087
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:01:54 PM

Document Has Been Signed on 04/12/2024 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BONNIE'S CARE HOMEFACILITY NUMBER:
502701087
ADMINISTRATOR/
DIRECTOR:		YEPEZ, BONAIREFACILITY TYPE:
740
ADDRESS:2608 VENEMAN AVENUETELEPHONE:
(209) 272-4444
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 3DATE:
04/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Angelica ChicasTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 4/12/24 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to open a complaint investigation for compliant number 27-AS-20240404104236. LPA Jensen met with Angela Chicas and explained the purpose of the visit. LPA Jensen also spoke to the Licensee/Administrator by phone and explained the visit.

While investigating the above listed allegation, it was learned that the facility had accepted a resident (R1) without creating and/or maintaining resident records as required by the California Code of Regulations (CCR) Title 22, Division 6, Section 87506. LPA Jensen asked the Licensee/Administrator asked the Licensee/Administrator which records were required prior to accepting a resident and she stated she was not aware. LPA Jensen reviewed the file for Resident 2 (R2) and observed no pre-placement appraisal and no physician's report (LIC 624). A review of the resident file for R2 revealed that R2 requires assistance for all Activities of daily living and is on hospice. During the course of this visit, a hospice nurse arrived to check on R2. LPA Jensen interviewed the hospice nurse who stated R2 has an unstageable sacrococcyx wound. R2 has at least 2 prohibited health conditions and no documentation was found that describes the type and frequency of the care tasks to be performed by the facility staff.

During the course of the investigation for complaint control number 27-AS-20240223144547, the Licensee/Administrator advised she was not aware that a copy of the admission agreement must be provided to the resident or responsible party upon signing.

Deficiencies are being cited from CCR, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties. . An exit interview was conducted and a copy of this report
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 02:01 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/12/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2024
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met based on:
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The Licensee will send an attestation by email to maja.jensen@dss.ca.gov by 4/13/24 that all current resident files will be reviewed and updated for compliance CCR 87506 by 5/12/24.
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Based on the Licensee/Administrator's own admission that facility records were not created upon acceptance of R1 and a lack of required records for R2 based on LPA Jensen's file review. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type B
05/12/2024
Section Cited
CCR87633(b)(4)

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Hospice Care of Terminally Ill Residents
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
...A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.
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The Licensee agrees to update all current resident files for residents on hospice with a comprehensive plan that is in compliance with CCR 87633 in it's entirety.
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This requirement was not met based on LPA Jensen's review of the resident file and lack of a hospice care plan for R2. This poses a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2024 02:01 PM - It Cannot Be Edited


Created By: Maja Jensen On 04/12/2024 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BONNIE'S CARE HOME
FACILITY NUMBER: 502701087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2024
Section Cited
CCR
87405(d)(2)

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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). ...
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met based on:
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The Licensee/Administrator agrees to complete an additional 5 hours of Administrator training with a focus on hospice care and record keeping.
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The Licensee/Administrator's own admission that she was not aware of requirements surrouding resident records and admission agreements. This poses a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024


LIC809 (FAS) - (06/04)
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